Assessing the built environment through photographs and its association with obesity in 21 countries: the PURE Study.

BACKGROUND: The built environment can influence human health, but the available evidence is modest and almost entirely from urban communities in high-income countries. Here we aimed to analyse built environment characteristics and their associations with obesity in urban and rural communities in 21 countries at different development levels participating in the Prospective Urban and Rural Epidemiology (PURE) Study. METHODS: Photographs were acquired with a standardised approach. We used the previously validated Environmental Profile of a Community's Health photo instrument to evaluate photos for safety, walkability, neighbourhood beautification, and community disorder. An integrated built environment score (ie, a minimum of 0 and a maximum of 20) was used to summarise this evaluation across built environment domains. Associations between built environment characteristics, separately and combined in the integrated built environment score, and obesity (ie, a BMI >30kg/m2) were assessed using multilevel regression models, adjusting for individual, household, and community confounding factors. Attenuation in the associations due to walking was examined. FINDINGS: Analyses include 143 338 participants from 530 communities. The mean integrated built environment score was higher in high-income countries (13·3, SD 2·8) compared with other regions (10·1, 2·5) and urban communities (11·2, 3·0). More than 60% of high-income country communities had pedestrian safety features (eg, crosswalks, sidewalks, and traffic signals). Urban communities outside high-income countries had higher rates of sidewalks (176 [84%] of 209) than rural communities (59 [28%] of 209). 15 (5%) of 290 urban communities had bike lanes. Litter and graffiti were present in 372 (70%) of 530 communities, and poorly maintained buildings were present in 103 (19%) of 530. The integrated built environment score was significantly associated with reduced obesity overall (relative risk [RR] 0·58, 95% CI 0·35-0·93; p=0·025) for high compared with low scores and for increasing trend (0·85, 0·78-0·91; p<0·0001). The trends were statistically significant in urban (0·85, 0·77-0·93; p=0·0007) and rural (0·87, 0·78-0·97; p=0·015) communities. Some built environment features were associated with a lower prevalence of obesity: community beautification RR 0·75 (95% CI 0·61-0·92; p=0·0066); bike lanes RR 0·58 (0·45-0·73; p<0·0001); pedestrian safety RR 0·75 (0·62-0·90; p=0·0018); and traffic signals RR 0·68 (0·52-0·89; p=0·0055). Community disorder was associated with a higher prevalence of obesity (RR 1·48, 95% CI 1·17-1·86; p=0·0010). INTERPRETATION: Community built environment features recorded in photographs, including bike lanes, pedestrian safety measures, beautification, traffic density, and disorder, were related to obesity after adjusting for confounders, and stronger associations were found in urban than rural communities. The method presents a novel way of assessing the built environment's potential effect on health. FUNDING: Population Health Research Institute, Hamilton Health Sciences Research Institute, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research's Strategy for Patient Oriented Research, Ontario Support Unit, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline.

Carbonated Beverage, Fruit Drink, and Water Consumption and Risk of Acute Stroke: the INTERSTROKE Case-Control Study.

BACKGROUND AND PURPOSE: Cold beverage intake (carbonated drinks, fruit juice/drinks, and water) may be important population-level exposures relevant to stroke risk and prevention. We sought to explore the association between intake of these beverages and stroke. METHODS: INTERSTROKE is an international matched case-control study of first stroke. Participants reported beverage intake using food frequency questionnaires or were asked "How many cups do you drink each day of water?" Multivariable conditional logistic regression estimated odds ratios (OR) and 95% confidence intervals (CI) for associations with stroke. RESULTS: We include 13,462 cases and 13,488 controls; mean age was 61.7±13.4 years and 59.6% (n=16,010) were male. After multivariable adjustment, carbonated beverages were linearly associated with ischemic stroke (OR 2.39 [95% CI 1.64-3.49]); only consumption once/day was associated with intracerebral hemorrhage (ICH) (OR 1.58 [95% CI 1.23-2.03]). There was no association between fruit juice/drinks and ischemic stroke, but increased odds of ICH for once/day (OR 1.37 [95% CI 1.08-1.75)] or twice/day (OR 3.18 [95% CI 1.69-5.97]). High water intake (>7 cups/day) was associated ischemic stroke (OR 0.82 [95% CI 0.68-0.99]) but not ICH. Associations differed by Eugeographical region-increased odds for carbonated beverages in some regions only; opposing directions of association of fruit juices/drinks with stroke in selected regions. CONCLUSION: Carbonated beverages were associated with increased odds of ischemic stroke and ICH, fruit juice/drinks were associated with increased odds of ICH, and high water consumption was associated with reduced odds of ischemic stroke, with important regional differences. Our findings suggest optimizing water intake, minimizing fruit juice/drinks, and avoiding carbonated beverages.

Prediction of visceral adipose tissue magnitude using a new model based on simple clinical measurements.

Aims: Waist circumference (WC) is a reliable obesity surrogate but may not distinguish between visceral and subcutaneous adipose tissue. Our aim was to develop a novel sex-specific model to estimate the magnitude of visceral adipose tissue measured by computed tomography (CT-VAT). Methods: The model was initially formulated through the integration of anthropometric measurements, laboratory data, and CT-VAT within a study group (n=185), utilizing the Multivariate Adaptive Regression Splines (MARS) methodology. Subsequently, its correlation with CT-VAT was examined in an external validation group (n=50). The accuracy of the new model in estimating increased CT-VAT (>130 cm2) was compared with WC, body mass index (BMI), waist-hip ratio (WHR), visceral adiposity index (VAI), a body shape index (ABSI), lipid accumulation product (LAP), body roundness index (BRI), and metabolic score for visceral fat (METS-VF) in the study group. Additionally, the new model's accuracy in identifying metabolic syndrome was evaluated in our Metabolic Healthiness Discovery Cohort (n=430). Results: The new model comprised WC, gender, BMI, and hip circumference, providing the highest predictive accuracy in estimating increased CT-VAT in men (AUC of 0.96 ± 0.02), outperforming other indices. In women, the AUC was 0.94 ± 0.03, which was significantly higher than that of VAI, WHR, and ABSI but similar to WC, BMI, LAP, BRI, and METS-VF. It's demonstrated high ability for identifying metabolic syndrome with an AUC of 0.76 ± 0.03 (p<0.001). Conclusion: The new model is a valuable indicator of CT-VAT, especially in men, and it exhibits a strong predictive capability for identifying metabolic syndrome.

Activity limitations, use of assistive devices, and mortality and clinical events in 25 high-income, middle-income, and low-income countries: an analysis of the PURE study.

BACKGROUND: The focus of most epidemiological studies has been mortality or clinical events, with less information on activity limitations related to basic daily functions and their consequences. Standardised data from multiple countries at different economic levels in different regions of the world on activity limitations and their associations with clinical outcomes are sparse. We aimed to quantify the prevalence of activity limitations and use of assistive devices and the association of limitations with adverse outcomes in 25 countries grouped by different economic levels. METHODS: In this analysis, we obtained data from individuals in 25 high-income, middle-income, and low-income countries from the Prospective Urban Rural Epidemiological (PURE) study (175 660 participants). In the PURE study, individuals aged 35-70 years who intended to continue living in their current home for a further 4 years were invited to complete a questionnaire on activity limitations. Participant follow-up was planned once every 3 years either by telephone or in person. The activity limitation screen consisted of questions on self-reported difficulty with walking, grasping, bending, seeing close, seeing far, speaking, hearing, and use of assistive devices (gait, vision, and hearing aids). We estimated crude prevalence of self-reported activity limitations and use of assistive devices, and prevalence standardised by age and sex. We used logistic regression to additionally adjust prevalence for education and socioeconomic factors and to estimate the probability of activity limitations and assistive devices by age, sex, and country income. We used Cox frailty models to evaluate the association between each activity limitation with mortality and clinical events (cardiovascular disease, heart failure, pneumonia, falls, and cancer). The PURE study is registered with ClinicalTrials.gov, NCT03225586. FINDINGS: Between Jan 12, 2001, and May 6, 2019, 175 584 individuals completed at least one question on the activity limitation questionnaire (mean age 50·6 years [SD 9·8]; 103 625 [59%] women). Of the individuals who completed all questions, mean follow-up was 10·7 years (SD 4·4). The most common self-reported activity limitations were difficulty with bending (23 921 [13·6%] of 175 515 participants), seeing close (22 532 [13·4%] of 167 801 participants), and walking (22 805 [13·0%] of 175 554 participants); prevalence of limitations was higher with older age and among women. The prevalence of all limitations standardised by age and sex, with the exception of hearing, was highest in low-income countries and middle-income countries, and this remained consistent after adjustment for socioeconomic factors. The use of gait, visual, and hearing aids was lowest in low-income countries and middle-income countries, particularly among women. The prevalence of seeing close limitation was four times higher (6257 [16·5%] of 37 926 participants vs 717 [4·0%] of 18 039 participants) and the prevalence of seeing far limitation was five times higher (4003 [10·6%] of 37 923 participants vs 391 [2·2%] of 18 038 participants) in low-income countries than in high-income countries, but the prevalence of glasses use in low-income countries was half that in high-income countries. Walking limitation was most strongly associated with mortality (adjusted hazard ratio 1·32 [95% CI 1·25-1·39]) and most consistently associated with other clinical events, with other notable associations observed between seeing far limitation and mortality, grasping limitation and cardiovascular disease, bending limitation and falls, and between speaking limitation and stroke. INTERPRETATION: The global prevalence of activity limitations is substantially higher in women than men and in low-income countries and middle-income countries compared with high-income countries, coupled with a much lower use of gait, visual, and hearing aids. Strategies are needed to prevent and mitigate activity limitations globally, with particular emphasis on low-income countries and women. FUNDING: Funding sources are listed at the end of the Article.

A comparison of brown fat tissue related hormone levels in metabolically healthy and unhealthy individuals with obesity.

PURPOSE: One of the key functions of brown adipose tissue is its positive impact on metabolism. This study aimed to examine the potential involvement of brown fat-related hormones in the development of metabolically healthy obesity. Specifically, we sought to compare the levels of NRG4, FGF21, and irisin between metabolically healthy and unhealthy individuals with obesity. METHODS: Patients with BMI ≥ 30 kg/m2 and aged between 20 and 50 years were included in the study. Among these patients, those who did not have any metabolic syndrome criteria except for increased waist circumference were defined as metabolically healthy obese. Age, gender, BMI, body fat, and muscle mass, matched metabolically healthy and unhealthy obese groups were compared in terms of FGF21, irisin, and NRG4 levels. RESULTS: Metabolically healthy and unhealthy obese groups were similar in terms of age and gender. There was no difference between the two groups in terms of BMI, weight, total body fat, muscle, fat-free mass, distribution of body fat and muscle mass. No statistically significant difference was found between irisin, NRG4, and FGF21 levels between metabolically healthy and unhealthy individuals with obesity. It was found that irisin had a significant inverse correlation with BMI and body fat percentage. CONCLUSION: The present study showed no difference between metabolically healthy and unhealthy obese individuals in terms of irisin, FGF21, and NRG4 levels. The weak association between irisin and BMI and body fat percentage may suggest a potential link between irisin with metabolic health.

Blood pressure variability in acute stroke: Risk factors and association with functional outcomes at 1 month.

BACKGROUND AND PURPOSE: Blood pressure variability, in acute stroke, may be an important modifiable determinant of functional outcome after stroke. In a large international cohort of participants with acute stroke, it was sought to determine the association of blood pressure variability (in the early period of admission) and functional outcomes, and to explore risk factors for increased blood pressure variability. PATIENTS AND METHODS: INTERSTROKE is an international case-control study of risk factors for first acute stroke. Blood pressure was recorded at the time of admission, the morning after admission and the time of interview in cases (median time from admission 36.7 h). Multivariable ordinal regression analysis was employed to determine the association of blood pressure variability (standard deviation [SD] and coefficient of variance) with modified Rankin score at 1-month follow-up, and logistic regression was used to identify risk factors for blood pressure variability. RESULTS: Amongst 13,206 participants, the mean age was 62.19 ± 13.58 years. When measured by SD, both systolic blood pressure variability (odds ratio 1.13; 95% confidence interval 1.03-1.24 for SD ≥20 mmHg) and diastolic blood pressure variability (odds ratio 1.15; 95% confidence interval 1.04-1.26 for SD ≥10 mmHg) were associated with a significant increase in the odds of poor functional outcome. The highest coefficient of variance category was not associated with a significant increase in risk of higher modified Rankin score at 1 month. Increasing age, female sex, high body mass index, history of hypertension, alcohol use, and high urinary potassium and low urinary sodium excretion were associated with increased blood pressure variability. CONCLUSION: Increased blood pressure variability in acute stroke, measured by SD, is associated with an increased risk of poor functional outcome at 1 month. Potentially modifiable risk factors for increased blood pressure variability include low urinary sodium excretion.

Follistatin as a Potential Biomarker for Identifying Metabolically Healthy and Unhealthy Obesity: A Cross-Sectional Study.

Metabolically healthy obesity (MHO) refers to obese individuals with a favorable metabolic profile, without severe metabolic abnormalities. This study aimed to investigate the potential of follistatin, a regulator of metabolic balance, as a biomarker to distinguish between metabolically healthy and unhealthy obesity. This cross-sectional study included 30 metabolically healthy and 32 metabolically unhealthy individuals with obesity. Blood samples were collected to measure the follistatin levels using an enzyme-linked immunosorbent assay (ELISA). While follistatin did not significantly differentiate between metabolically healthy (median 41.84 [IQR, 37.68 to 80.09]) and unhealthy (median 42.44 [IQR, 39.54 to 82.55]) individuals with obesity (p = 0.642), other biochemical markers, such as HDL cholesterol, triglycerides, C-peptide, and AST, showed significant differences between the two groups. Insulin was the most significant predictor of follistatin levels, with a coefficient of 0.903, followed by C-peptide, which exerted a negative influence at -0.624. Quantile regression analysis revealed nuanced associations between the follistatin levels and metabolic parameters in different quantiles. Although follistatin may not serve as a biomarker for identifying MHO and metabolically unhealthy obesity, understanding the underlying mechanisms that contribute to metabolic dysfunction could provide personalized strategies for managing obesity and preventing associated complications.

Is ChatGPT an Accurate and Reliable Source of Information for Patients with Vaccine and Statin Hesitancy?

Objective: Chat Generative Pre-trained Transformer (ChatGPT) is an artificial intelligence (AI) language model that is trained to respond to questions across a wide range of topics. Our aim is to elucidate whether it would be beneficial for patients who are hesitant about vaccines and statins to use ChatGPT. Methods: This cross-sectional and observational study was conducted from March 2 to March 30, 2023, using OpenAI ChatGPT-3.5. ChatGPT provided responses to 7 questions related to vaccine and statin hesitancy. The same questions were also directed at physicians. Both the answers from ChatGPT and the physicians were assessed for accuracy, clarity, and conciseness by experts in cardiology, internal medicine, and microbiology, who possessed a minimum of 30 years of professional experience. Responses were rated on a scale of 0-4, and the ChatGPT's average score was compared with that of physicians using the Mann-Whitney U test. Results: The mean scores of ChatGPT (3.78±0.36) and physicians (3.65±0.57) were similar (Mann-Whitney U test p=0.33). The mean scores of ChatGPT were 3.85±0.34 for vaccination and 3.68±0.35 for statin use. The mean scores of physicians were 3.73±0.51 for vaccination and 3.58±0.61 for statin use. There was no statistically significant difference between the mean scores of ChatGPT and physicians for both vaccine and statin use (p=0.403 for vaccination, p=0.678 for statin). ChatGPT did not consider sources of conspiratorial information on vaccines and statins. Conclusions: This study suggests that ChatGPT can be a valuable source of information for guiding patients with vaccine and statin hesitancy.

Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study.

Background: Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. Methods: The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). Findings: Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50). Interpretation: There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. Funding: The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case­control study

BACKGROUND Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. METHODS The INTERSTROKE study is a case­control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). FINDINGS Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46­1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61­2.11) than ICH (OR 1.19 95% CI 1.00­1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24­4.10) and PAR (18.6%, 15.1­22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63­2.87) and undetermined cause (OR 1.97, 95% CI 1.55­2.50). Both filtered (OR 1.73, 95% CI 1.50­1.99) and non-filtered (OR 2.59, 95% CI 1.79­3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69­2.27), ischemic stroke (OR 1.89, 95% CI 1.59­2.24) and ICH (OR 2.00, 95% CI 1.60­2.50). INTERPRETATION There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. FUNDING The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

The relation of C-reactive protein and impaired fasting glucose: Could it be a predictor for prediabetic state?

OBJECTIVE: The rate of cardiovascular disease is increasing in developed countries progressively with estimates predicting 22 million by 2030. Based on these cardiovascular events lies atherosclerosis, a condition intricately linked to chronic inflammatory processes. Among fundamental clinical biomarkers, C-reactive protein (CRP) stands out as a backbone of inflammatory activity. Notably, the excessive production of CRP, often linked with obesity, plays a pivotal role in the dysregulation of triglyceride apo B-100 fractional catabolism, thus emerging as a significant cardiovascular risk factor. Apart from atherosclerotic processes, the interplay between high CRP levels and impaired fasting glucose (IFG) is also gaining recognition as a messenger of disrupted glucose metabolism, potentially ushering in the onset of a prediabetic state. METHODS: Our retrospective analysis scrutinized the biochemical data - namely low-density lipoprotein cholesterol (LDL-C), triglycerides, fasting blood sugar, and CRP levels-of 3500 patients from an internal medicine outpatient clinic seen from August 2006 to May 2007. Our objective was to dissect the correlations among these parameters. Exclusion criteria were omitting individuals with acute or chronic inflammation, known inflammatory diseases, diagnosed diabetes, coronary artery disease, lipid metabolism disorders, those on lipid-lowering agents, and anyone outside the age bracket of 18-65 years. This study was conducted in strict adherence to the ethical principles outlined in the Declaration of Helsinki. RESULTS: As a result of our study, the ratio of CRP levels above 0.8 was significantly higher in patients with IFG according to the World Health Organization criteria (6.1-6.9 mmol/L or 109-124 mg/dL) than in individuals with normal fasting glucose (70-108 mg/dL). (19.7%, 17.2%, respectively) (p<0.001). In addition, the ratio of CRP levels above 0.8 was also higher in patients with triglyceride levels between 151 and 199 mg/dL) and over 500 mg/dL. (23.2%, 24.1%, respectively) (p<0.012). However, the relationship between CRP levels and LDL-C total cholesterol was not statistically significant (p>0.05). CONCLUSION: This retrospective study suggests the imperative for a proactive approach in the clinical evaluation of patients exhibiting elevated CRP, especially in the context of preemptive management of prediabetes. In light of these findings, we think that elevated CRP may be a warning sign for prediabetic status and may be useful in early diagnosis.

Variations in the prevalence of atrial fibrillation, and in the strength of its association with ischemic stroke, in countries with different income levels: INTERSTROKE case-control study

BACKGROUND: The contribution of atrial fibrillation (AF) to the etiology and burden of stroke may vary by country income level. AIMS: We examined differences in the prevalence of AF and described variations in the magnitude of the association between AF and ischemic stroke by country income level. METHODS: In the INTERSTROKE case­control study, participants with acute first ischemic stroke were recruited across 32 countries. We included 10,363 ischemic stroke cases and 10,333 community or hospital controls who were matched for age, sex, and center. Participants were grouped into high-income (HIC), upper-middle-income (subdivided into two groups­UMIC-1 and UMIC-2), and lower-middle-income (LMIC) countries, based on gross national income. We evaluated the risk factors for AF overall and by country income level, and evaluated the association of AF with ischemic stroke. RESULTS: AF was documented in 11.9% (n = 1235) of cases and 3.2% (n = 328) of controls. Compared to HIC, the prevalence of AF was significantly lower in UMIC-2 (aOR 0.35, 95% CI 0.29­0.41) and LMIC (aOR 0.50, 95% CI 0.41­0.60) on multivariable analysis. Hypertension, female sex, valvular heart disease, and alcohol intake were stronger risk factors for AF in lower-income countries, and obesity a stronger risk factor in higher-income countries. The magnitude of association between AF and ischemic stroke was significantly higher in lower-income countries compared to higher-income countries. The population attributable fraction for AF and stroke varied by region and was 15.7% (95% CI 13.7­17.8) in HIC, 14.6% (95% CI 12.3­17.1) in UMIC-1, 5.7% (95% CI 4.9­6.7) in UMIC-2, and 6.3% (95% CI 5.3­7.3) in LMIC. CONCLUSION: Risk factors for AF vary by country income level. AF contributes to stroke burden to a greater extent in higher-income countries than in lower-income countries, due to a higher prevalence and despite a lower magnitude of odds ratio.

Variations in the prevalence of atrial fibrillation, and in the strength of its association with ischemic stroke, in countries with different income levels: INTERSTROKE case-control study.

BACKGROUND: The contribution of atrial fibrillation (AF) to the etiology and burden of stroke may vary by country income level. AIMS: We examined differences in the prevalence of AF and described variations in the magnitude of the association between AF and ischemic stroke by country income level. METHODS: In the INTERSTROKE case-control study, participants with acute first ischemic stroke were recruited across 32 countries. We included 10,363 ischemic stroke cases and 10,333 community or hospital controls who were matched for age, sex, and center. Participants were grouped into high-income (HIC), upper-middle-income (subdivided into two groups-UMIC-1 and UMIC-2), and lower-middle-income (LMIC) countries, based on gross national income. We evaluated the risk factors for AF overall and by country income level, and evaluated the association of AF with ischemic stroke. RESULTS: AF was documented in 11.9% (n = 1235) of cases and 3.2% (n = 328) of controls. Compared to HIC, the prevalence of AF was significantly lower in UMIC-2 (aOR 0.35, 95% CI 0.29-0.41) and LMIC (aOR 0.50, 95% CI 0.41-0.60) on multivariable analysis. Hypertension, female sex, valvular heart disease, and alcohol intake were stronger risk factors for AF in lower-income countries, and obesity a stronger risk factor in higher-income countries. The magnitude of association between AF and ischemic stroke was significantly higher in lower-income countries compared to higher-income countries. The population attributable fraction for AF and stroke varied by region and was 15.7% (95% CI 13.7-17.8) in HIC, 14.6% (95% CI 12.3-17.1) in UMIC-1, 5.7% (95% CI 4.9-6.7) in UMIC-2, and 6.3% (95% CI 5.3-7.3) in LMIC. CONCLUSION: Risk factors for AF vary by country income level. AF contributes to stroke burden to a greater extent in higher-income countries than in lower-income countries, due to a higher prevalence and despite a lower magnitude of odds ratio.

The effect of close and intensive therapeutic monitoring of patients with poorly controlled type 2 diabetes with different glycemic background.

Patients with type 2 diabetes who have HbA1c values ≥ 10% have different previous glycemic trends, including new diagnosis of diabetes. We aimed to assess the efficacy of 3 months of intensive and facilitated antihyperglycemic treatment in patients with different glycemic backgrounds. In this observational study, patients with type 2 diabetes and poor glycemic control (indicated by an HbA1c level of > = 10%) were divided into groups based on their previous HbA1c levels (group 1; newly diagnosed type 2 diabetics, group 2; patients with previously controlled but now deteriorated HbA1c levels, group 3; patients whose HbA1c was not previously in the target range but was now above 10%, and group 4; patients whose HbA1c was above 10% from the start). Patients received intensive diabetes management with close monitoring and facilitated hospital visits. For further analysis, patients who were known to have previously had good metabolic control (either did not have diabetes or had previously had an HbA1c value < =7) and patients who had prior poor metabolic control were analyzed separately. Of the 195 participants [female, n = 84 (43.1%)], the median age was 54 years (inter-quantile range [IQR] = 15, min = 29, max = 80) and the median baseline HbA1c was 11.8% (IQR = 2.6%, min = 10%, max = 18.3%). The median duration of diabetes was 10 years (IQR = 9, min = 1, max = 35) when newly diagnosed patients were excluded. The ≥ 20% reduction in HbA1c at month 3 was observed in groups 1 to 4 in 97%, 88.1%, 69.1%, and 55.4%, respectively. The percentage of patients who achieved an HbA1c level of 7% or less was 60.6%, 38.1%, 16.4%, and 6.2% in the groups, respectively. The rate of those who achieved an HbA1c of 7% or less was nearly 50% of patients with type 2 diabetes mellitus who had previously had good metabolic control, whereas successful control was achieved in only 1 in 10 patients with persistently high HbA1c levels. Patients' glycemic history played an important role in determining their HbA1c levels at 3 months, suggesting that previous glycemic management patterns may indicate future success in diabetes control.

Is Metabolic Score for Visceral Fat (METS-VF) a Better Index Than Other Adiposity Indices for the Prediction of Visceral Adiposity.

Background: Visceral adiposity is an important risk factor for cardiometabolic diseases. Objective: To determine whether the Metabolic Score for Visceral Fat (METS-VF) is more effective than other adiposity indices in predicting visceral fat area (VFA). Methods: In this single-center and cross-sectional study, we included patients aged 20-50 years, without diabetes and coronary artery disease, who underwent computed tomography (CT) including the third lumbar vertebra. Age, blood pressure, waist circumference (WC), hip circumference, fasting lipids, and glucose were assessed. VFA was measured by cross-sectional examination of CT. The correlation of WC, body mass index (BMI), waist-hip ratio (WHR), lipid accumulation product (LAP), visceral adiposity index (VAI), a body shape index (ABSI), body roundness index (BRI), and METS-VF with VFA was analyzed by correlation analysis. The cut-off values and area under the curve (AUC) for identifying increased VFA (>130 cm2) were determined. Results: We included 185 individuals with mean age 38.2 ± 8 and female predominance (58.4%). There was a significant positive correlation between all indices and VFA (p<0.001). ROC analysis revealed that METS-VF and WC demonstrated the highest predictive value for identifying increased VFA. In both men (p=0.001) and women (p<0.001), METS-VF (AUC 0.922 and 0.939, respectively) showed a significant superiority over ABSI (AUC 0.702 and 0.658, respectively), and VAI (AUC 0.731 and 0.725, respectively). Additionally, in women, its superiority over WHR (AUC 0.807) was also statistically significant (p=0.003). We identified a METS-VF cut-off point >6.4 in males >6.5 in females and WC cut-off point >88 cm in males (AUC 0.922), >90.5 cm in females (AUC 0.938). Conclusion: METS-VF is strongly associated with visceral adiposity and better to predict increased VFA. However, its superiority over WC, BMI, BRI, and LAP was not significant. The results emphasize that WC is more appealing as screening indicator for visceral adiposity considering its easy use. Clinical Trial Registry Name: Clinicaltrials.gov (http://www.clinicaltrials.gov). Clinical Trial Registry Url: https://clinicaltrials.gov/ct2/show/NCT05648409. Clinical Trial Registry Number: NCT05648409.

Risk Factors, Use of Preventive Drugs, and Cardiovascular Events in Diabetes Mellitus: The PURE Türkiye Cohort.

BACKGROUND: The risk of cardiovascular disease is correlated with the frequency and control of associated risk factors in diabetes mellitus and may vary according to country. We evaluated risk factors for cardiovascular disease, cardiovascular events, and the use of preventive medications in patients with diabetes mellitus using the Prospective Urban and Rural Epidemiological Türkiye cohort. METHODS: Patients with diabetes mellitus versus without diabetes mellitus were compared for risk factors, cardioprotective drugs (angiotensin-converting enzyme inhibitors or angiotensin-II receptor antagonists, statins, and antiplatelets), and cardiovascular events. The primary outcome was major cardiovascular events (composite of cardiovascular death, myocardial infarction, stroke, or heart failure). RESULTS: Among 4041 participants, 549 (13.6%) had diabetes mellitus. The mean age (54.8 ± 8.4 vs. 49.3 ± 9.0 years, P <.001) and proportion of women (65.4% vs. 59.9%, P =.014) were higher in diabetics compared with non-diabetics. Hypertension, history of coronary heart disease, and use of statin, antiplatelets, and angiotensin-converting enzyme inhibitors or angiotensin-II receptor antagonists were more common in diabetics; however, the use of these medications at baseline was lower than optimal even in patients with diabetes mellitus and concomitant coronary heart disease (statin 31.2%, antiplatelets 46.9%, and angiotensin-converting enzyme inhibitors or angiotensin-II receptor antagonists 54.7%). During 11.5 years of follow-up, major cardiovascular events occurred in 288 (7.1%) patients, and the risk was higher in diabetics [hazard ratio (95% confidence interval) 1.71 (1.30-2.24); P <.001]. The increase in the risk of future events was comparable for those with diabetes mellitus alone without cardiovascular disease [hazard ratio 1.62 (1.20-2.20)] versus those with cardiovascular disease alone without diabetes mellitus [hazard ratio 1.31 (0.83-2.07)] and was additive in those with both conditions [hazard ratio 2.79 (1.65-4.69)]. The risk of major coronary events (myocardial infarction, angina, percutaneous, or surgical coronary intervention) was also higher in diabetes mellitus [hazard ratio 1.64 (1.26-2.15); P <.001]. CONCLUSION: Patients with diabetes mellitus have a higher risk of major cardiovascular events, and the risk is comparable to that observed in those with cardiovascular disease but no diabetes mellitus. The use of preventive medicines for cardiovascular diseases is disturbingly low in diabetics.

Risk Factors for Stroke in the Young (18-45 Years): A Case-Control Analysis of INTERSTROKE Data from 32 Countries.

BACKGROUND: It is not clear whether conventional vascular risk factors are responsible for most strokes in patients younger than 45 years of age. Our objective was to evaluate the association of common risk factors with stroke in individuals under 45 years. METHODS: INTERSTROKE was a case-control study carried out in 32 countries between 2007 and 2015. Patients presenting within 5 days of symptom onset of a first stroke were enrolled as cases. Controls were age and sex matched to cases and had no history of stroke. Cases and controls underwent similar evaluations. Odds ratios (ORs) and population attributable risks (PARs) were calculated to determine the association of various risk factors with all stroke, ischemic stroke, and intracranial hemorrhage, for patients 45 years of age or younger. FINDINGS: 1,582 case-control pairs were included in this analysis. The mean age of this cohort was 38.5 years (SD 6.32). Overall, 71% strokes were ischemic. Cardiac causes {OR: 8.42 (95% confidence interval [CI]: 3.01-23.5)}; binge drinking of alcohol (OR: 5.44 [95% CI: 1.81-16.4]); hypertension (OR: 5.41 [95% CI: 3.40-8.58]); ApoB/ApoA1 ratio (OR: 2.74 [95% CI: 1.69-4.46]); psychosocial stress (OR: 2.33 [95% CI: 1.01-5.41]); smoking (OR: 1.85 [95% CI: 1.17-2.94]); and increased waist-to-hip ratio (OR: 1.69 [95% CI: 1.04-2.75]) were the most important risk factors for ischemic stroke in these young cases. For intracerebral hemorrhage, only hypertension (OR: 9.08 [95% CI: 5.46-15.1]) and binge drinking (OR: 4.06 [95% CI: 1.27-13.0]) were significant risk factors. The strength of association and population attributable risk (PAR) for hypertension increased with age (PAR 23.3% in those <35 years of age, 50.7% in 35-45 years of age). INTERPRETATION: Conventional risk factors such as hypertension, smoking, binge drinking of alcohol, central obesity, cardiac causes, dyslipidemia, and psychosocial stress are important risk factors for stroke in those younger than 45 years of age. Hypertension is the most significant risk factor in all age groups and across all regions and both stroke subtypes. These risk factors should be identified and modified in early adulthood to prevent strokes in young individuals.

The effect of Ramadan fasting on serum osmolality in diabetic patients.

OBJECTIVE: To observe the changes of osmolarity levels due to fasting in Ramadan among type 2 diabetic patients. METHODS: The observational study was conducted from May 16 to June 3, 2019, at the Istanbul Medeniyet University, Istanbul, Turkey, and comprised adult type 2 diabetic patients of either gender visiting the diabetes outpatient clinics during the holy month of Ramadan. Those fasting were placed in Group A, while those not fasting formed Group B. Anthropometric measurements and medications in use were recorded. Blood samples were taken in the morning and before the evening meal. Serum osmolality was calculated using serum levels of sodium, glucose and blood urea nitrogen. Data was analysed using SPSS 16. RESULTS: Of the 52 patients, 27(52%) were in Group A and 25(48%) were in Group B. Overall, there were 22(42%) females and 30(58%) males. The mean morning serum osmolalities of the two groups were not different (p>0.05). The mean evening serum osmolality was not significantly different than the mean morning osmolality in Group A (p=0.22). In Group B, the mean evening serum osmolality was significantly lower than the mean morning osmolality (p=0.004). No significant difference was found between mean morning and evening serum osmolalities of those taking sodium-glucose cotransporter 2 (p>0.05). CONCLUSIONS: There was no biochemical sign of dehydration with Ramadan fasting in type 2 diabetes mellitus patients. Clinical Trial Number: [NCT04392570] Link: https://clinicaltrials.gov/.